AO Principles Of Fracture

Treatment And Different

Implant Modalities

Dr. Anshu sharma

 AO System Of Classification
 AO Classification is based on the
Type of involved bone (no. 1 to 9),
Part of involved bone (no. 1 to 3),
Fracture is extraarticular, partially
articular or intraarticular ( A,B or C),
Pattern of fracture (1 to 3).
 AO Principles
 The four AO principles of fracture fixation are:-
1. Fracture reduction to restore anatomical
relationships.
2. Fracture fixation providing absolute or relative
stability as the “personality” of fracture, patient and
injury requires.
3. Preservation of blood supply to soft tissues and
bone.
4. Early and safe mobilization of the injured part and
the patient as a whole.
 Fracture Reduction
 Aim of reduction
Some fractures are reduced to restore
1. The bony anatomy and morphology, when perfect
anatomical reduction is required.
2. The relationship between the proximal and distal main
fragments. Length, alignment and rotation are restored.
This is functional reduction .

 Reduction methods
The decision, which reduction method should be used,
depends on the location of the fracture:
1. Meta- and diaphyseal fractures usually need
functional reduction.
2. Joint fractures need anatomical reduction.
 Reduction of diaphyseal fractures
• The functional anatomy is restored (length, alignment,
and rotational axis).
• The load-bearing axis of the extremity is restored
(especially important in the lower limb).
• An exception is the forearm which functions as a single
articular unit.

 Reduction of articular fractures

• The joint surface is restored anatomically.Gaps and steps
in the articular surface must be avoided.
 “Steps” means that there is a difference between the
levels of two main articular fragments.
 “Gaps” means that there is some space between two
adjacent main articular fragments.
 The axial alignment is restored.
 Fracture Fixation
 Goal of fracture fixation
1. To maintain the reduction
2. To create adequate stability which:
-Allows early and optimal function of the injured limb,
-Minimizes pain.
 The main goal of internal fixation is to achieve prompt

and, if possible, full function of the injured limb. Although

reliable fracture healing is only one element in functional
recovery, its mechanics, biomechanics, and biology are
essential for a good outcome.
 Absolute stability
• There is no movement at fracture site.
• It is achieved by interfragmentary compression,
eg. lag screws, compression plate.
• There is no callus formation.Direct bone healing
is achieved.
 Relative stability
• Movement at fracture site
• There is no interfragmentary
compression at fracture
site.It is achieved by splinting
or bridging, eg. elastic nails
• There is callus formation.
Indirect bone healing is
achieved.
 Spectrum of Stability

IM Nail

Ex Fix

Cast Bridge Plating Compression

Plating/ Lag
screw

Relative Absolute
(Flexible) (Rigid)
 Practically speaking….
 Most fixation probably involves
components of both types of healing.
 Even in situations of excellent rigid internal
fixation one often sees a small degree of
callus formation.
 Fixation Stability

Reality

Callus No
callus
Absolute Relative
(Flexible) (Rigid)
 Preservation Of Blood Supply
Care for the soft tissues
• Evaluation of limb swelling.
• Consideration for staged procedure is important:
- Primary stabilization → external fixation.
- Secondary stabilization → definitive fixation.
• Careful reduction procedure
-Too intense efforts for perfect reduction are
risky and Increases infection rate.
• Minimal invasive surgery.
• Good Nursing care of patient with fractures and Care
during transfer and positioning.
 Postoperative care
• Immediately after surgery,the treated extremity is
positioned above the level of the heart to minimize
swelling.

 Adequate pain control.

 Thrombosis prophylaxis.
 Early recognition and treatment of complications.
 Early joint motion: CPM (continuous passive motion) machines are
used to provide a continuous but passive (without force of the
patient) motion for limbs where after surgery (knee or elbow)
stiffness of the limb might be expected.

 Partial weight bearing and gradually full weight bearing.

 During follow-up treatment, not only look at the xrays but also at the
injured limb. Pain, swelling, and tenderness are signs of either
instability or infection.
 Indications for Internal Fixation

 Displaced intra-articular fracture,

 Axial, angular, or rotational instability that
cannot be controlled by closed methods,
 Open fracture,
 Polytrauma patients,
 Associated neurovascular injury.
 Benefits of Internal Fixation
 Earlier functional recovery,

 More predictable fracture alignment,

 Potentially faster time to healing.

 Screws
• Cortical screws:
-Greater number of threads
-Threads spaced closer together
(smaller pitch)
-Outer thread diameter to core diameter
ratio is less
-Better hold in cortical bone.
• Cancellous screws:
-Larger thread to core diameter ratio
-Threads are spaced farther apart
(greater pitch)
-Lag effect with partially-threaded
screws
-Theoretically allows better fixation in
cancellous bone Figure from: Rockwood and Green’s, 5th ed.
 Lag Screw Fixation
 Screw compresses both
sides of fx together
 Best form of compression
 Poor shear, bending, and
rotational force resistance
 Partially-threaded screw
(lag by design)
 Fully-threaded screw (lag
by technique)
 Lag Screws
• “Lag by technique”
• Using fully-threaded
1
screw
• Step One: Gliding hole =
drill outer thread diameter of 2
screw & perpendicular to fx.
• Step Two: Pilot hole= Guide
sleeve in gliding hole & drill
far cortex = to the core Figure from: Schatzker J, Tile M: The Rationale of
Operative Fracture Care. Springer-Verlag, 1987.
diameter of the screw.
 Lag Screws
 Step Three: counter sink
near cortex so screw head
will sit flush
 Step Four: screw inserted
and glides through the near
cortex & engages the far
cortex which compresses
the fx when the screw head
Figure from: Schatzker J, Tile M: The
Rationale of Operative Fracture Care.
Springer-Verlag, 1987.

engages the near cortex

 Lag Screws
 Functional Lag  Position Screw -
Screw - note the note the near cortex
near cortex has has not been drilled
been drilled to the to the outer
outer diameter = diameter = lack of
compression compression & fx
gap maintained
 Lag Screws

• Malposition of screw, or neglecting to

countersink can lead to a loss of reduction
• Ideally lag screw should pass perpendicular to fx

Figure from: OTA Resident Course - Olsen

 Neutralization Plates

 Neutralizes/protect
s lag screws from
shear, bending,
and torsional forces
across fx
 “Protection Plate"

Figure from: Schatzker J, Tile M: The Rationale of

Operative Fracture Care. Springer-Verlag, 1987.
 Buttress / Antiglide Plates
 “Hold” the bone up.
 Resist shear forces
during axial loading.
 Used in metaphyseal
areas to support intra-
articular fragments.
 Plate must match
contour of bone to truly
provide buttress effect.
 Bridge Plates

 “Bridge”/bypass
comminution.
 Proximal & distal
fixation.
 Goal: Maintain length,
rotation, & axial
alignment
 Avoids soft tissue
disruption at fx to
maintain fx blood
supply.
 Tension Band Plates
 Plate counteracts natural
bending moment seen with
physiologic loading of
bone
 Applied to tension side to
prevent “gapping”.
 Plate converts bending force
to compression.
 Examples: Proximal Femur
& Olecranon.
 Compression Plating
 Reduce & Compress
transverse or oblique
fx’s.
 Unable to use lag
screw
 Exert compression
across fracture
 Pre-bending plate
 External compression
devices (tensioner)
 Dynamic compression
w/ oval holes &
eccentric screw
placement in plate
 Examples- 3.5 mm Plates
 LC-Dynamic
Compression Plate:
 stronger and stiffer
 more difficult to contour.
 usually used in the
treatment radius and ulna
fractures
 Semitubular plates:
 very pliable Figure from: Rockwood and Green’s, 5th ed.
 limited strength
 most often used in the Figure from: Rockwood and Green’s, 5th ed.
treatment of fibula
fractures.
 Dynamic Compression Plating
 Compression applied
via oval holes and
eccentric drilling
 Plate forces bone to
move as screw
tightened =
compression
 Dynamic Compression Plates
• Note the screw holes in the
plate have a slope built into
one side.

• The drill hole can be purposely

placed eccentrically so that when
the head of the screw engages the
plate, the screw and the bone
beneath are driven or compressed
towards the fracture site one
millimeter.

This maneuver can be

Figure from: Schatzker J, Tile M: The Rationale of
performed twice before
Operative Fracture Care. Springer-Verlag, 1987. compression is maximized.
 Locking Plates

 Screw head has threads

that lock into threaded
hole in the plate
 Creates a “fixed angle” at
each hole
 Theoretically eliminates
individual screw failure
 Plate-bone contact not
critical Courtesy AO Archives
 Locking Plates
 Must have reduction and compression
done prior to using locking screws
 CANNOT PUT CORTICAL SCREW OR LAG
SCREW AFTER LOCKING SCREW
 Locking Plates

 Increased axial
stability
 It is much less
likely that an
individual screw
will fail
 But, plates can
still break
 Locking Plates
 Indications:
 Osteopenic bone
 Metaphyseal
fractures with short
articular block
 Bridge plating
 Intramedullary Nails
 Relative stability
 Intramedullary splint
 Less likely to break with
repetitive loading than
plate
 More likely to be load
sharing (i.e. allow axial
loading of fracture with
weight bearing).
 Secondary bone healing
 Diaphyseal and some
metaphyseal fractures
 Intramedullary Fixation
 Rotational and axial
stability provided by
interlocking bolts.
 Reduction can be
technically difficult in
segmental and
comminuted
fractures.
 Maintaining reduction
of fractures in close
proximity to
metaphyseal flare
may be difficult.
• Open segmental
tibia fracture treated
with a reamed,
locked IM Nail.
• Intertrochanteric/
Subtrochanteric fracture
treated with closed IM
Nail

• The goal:
• Restore length,
alignment, and
rotation
• NOT anatomic
reduction

• Without extensive
exposure this fracture
formed abundant callus Valgus is restored...
by 6 weeks
 Failure to Apply Concepts
•Classic example of
inadequate fixation &
stability

•Narrow, weak plate that is

too short
•Insufficient cortices engaged
with screws through plate
•Gaps left at the fx site

Unavoidable result =
Nonunion Figure from: Schatzker J, Tile M: The Rationale of
Operative Fracture Care. Springer-Verlag, 1987.
 Summary
 Respect soft tissues.
 Choose appropriate fixation method.
 Achieve length, alignment, and
rotational control to permit motion as
soon as possible.
 Understand the requirements and
limitations of each method of internal
fixation.